Hospital E/M question

When our providers see a patient in the hospital sometimes the patient is listed as outpatient with observation service. We trying to figure out if we use the outpatient codes (99201-99215) or do we use the observation code (99218-99220) for the e/m. Any ideas?


  • What we do is the provider we are coding for is the admitting physician we use 99218-99220 but if he is the PCP or consulting & not admitting we use the outpatient new/established or consult codes depending on circumstances.

    Laurie Johnson
    Laurie Johnson, CCS, COC
    Certified Coder
    Hannibal Regional Healthcare System
    573-248-5421 (O)

  • edited June 2017
    You want to use the subsequent observation codes if you are not the provider who admitted patient to observation. Only the admitting physician can bill initial obs codes (which differs from initial inpatient codes). If it's the rare the payor who still pays for consults and it was actually a consult, then the outpatient consult codes would be appropriate.

    “New or Established Patient Initial Hospital Observation Care Services

    The following codes are used to report the encounter(s) by the supervising physician or other qualified health care professional with the patient when designated as "observation status." This refers to the initiation of observation status, supervision of the care plan for observation and performance of periodic reassessments. For observation encounters by other physicians, see office or other outpatient consultation codes (99241-99245) or subsequent observation care codes (99224-99226) as appropriate."

  • For Medicare, a consulting provider should bill new or established outpatient code with location 22.

    See CMS CPM Chapter 12. 30.6.8 section A:

    For example, if an internist orders observation services and asks another physician to additionally evaluate the patient, only the internist may bill the initial and subsequent observation care codes. The other physician who evaluates the patient must bill the new or established office or other outpatient visit codes as appropriate.

  • edited June 2017
    We run into a problem using the subsequent codes for Humana, they are denying saying only one provider a day is allowed to bill the admission or the subsequent codes. We are general surgery so when we get consulted it becomes an issue.

    Jennifer Cossin
    Billing Manager
    Central Ohio Surgical Associates, Inc.
    (614) 866-4270
    (614) 866-4271 (fax)

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  • edited June 2017
    We are getting these too. We are appealing, with a letter stating different taxonomy codes, different practices, and different specialties.


    Deborah Broyles, CPC
    Supervisor/Coding Specialist
    University Radiation Oncology/University Surgical Oncology
    865-305-9886 phone / 865-305-9714 Fax

    Notice & Disclaimer:  The information given in this email is intended as generalized coding guidance and should not be misinterpreted as medical, health, legal or financial advice. Furthermore, it is the responsibility of the provider to code services as they are documented in the permanent medical record following federal and state regulations, as well as carrier specific guidelines. Any information given should not be modified in any way, sold for profit or shared without the express permission of UPA. While all information given is thoroughly researched and believed to be correct, recipients of this email accept responsibility for their own coding and documentation.

  • edited June 2017
    That is correct. Only the provider (or group) that admitted the patient to obs can charge the subs obs charges. Anyone else has to bill the new or established outpatient codes 99201-99215

  • Add different diagnoses.

    Maxine Lewis, CMM, CPC, CPC-I, CCS-P, CPMA
    Main: 513-771-7070
    Direct: 513-672-4363
    Fax: 513-326-7640
    200 Northland Blvd
    Cincinnati, OH 45246

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  • Both Erica and Leann were correct, depending on the payer.

    Here's the dealio:

    When the Subsequent Observation Care codes were released, CPT said that they could be used in much the same way as Subsequent (Inpatient) Hospital Care codes were, in that they were to be used primarily by the admitting specialty for care occurring between the day of admission and the day of discharge—true—but were also available for use by other specialties seeing the admitted patient during any day of their stay when a consult code did not apply. For CPT, only the Initial Care and Discharge code categories were restricted for use only by the admitting/attending specialty.

    Medicare, in their never-ending desire to be different, took a more restrictive stance for the new Subsequent Observation Care codes, and said that only the admitting/attending specialties could use the subsequent visit codes from this particular category and that other specialties seeing the patient should bill for observation care using the Outpatient Office Visit codes.

    Some Medicare managed care plans followed Medicare's lead, while almost every commercial insurer that I know of follows CPT's direction. So everybody is right, depending on the payer. :)


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